New Pet(S) Form (Client Intake Form) printable pdf download

ASHEVILLE HIGHWAY ANIMAL HOSPITAL, LLC

NEW PET(S) FORM

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please

complete the following:

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CLIENT INFORMATION (

Existing Client OR

New Client)

Date ________________________

Primary Owner Name _____________________________________ Home Phone ___________________________________

Address _________________________________ City _____________________ State ______ Zip _________________________

Place of Employment _____________________ Work Phone ________________ Cell Phone #__________________________

Social Security # _________________ Driver’s License # __________________________ E-Mail Address __________________

□

Is it okay to send text message appointment reminders?

YES

Is it okay to send correspondence via email?

YES

Under the laws of HIPPA (Heath Insurance Portability and Accountability Act), we cannot disclose any personal information about you or your pet to anyone unless

otherwise specified by you. The following individuals are authorized to make health and financial decisions for all my current pets.

Co-Owner’s Name ________________________Co-owner’s Phone

Additional Authorized Names: _____________________________________________________________________

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□O

How did you become aware of our clinic? €

Sign €

Yellow Pages €

New Resident Letter €

ther

Personal Recommendation/Previous Client (Whom may we thank?)

Please indicate choice of payment.

€ □Cash € □Check € □ Visa □MasterCard € □Discover □Care Credit □H3 Wellness Plus Card

All Fees Are Due At the Time Services Are Rendered

Due to the Red Flag Rules, we require a matching ID for all credit card and check payments.

PET(S) INFORMATION

PET # 1

PET # 2

PET # 3

NAME

BREED

DATE OF BIRTH OR AGE

COLOR

SEX; SPAYED OR NEUTERED?

MICROCHIPPED?

YOUR DOG’S VACCINATION HISTORY (Last date given):

RABIES

DHLP PARVO

BORDETELLA

CORONA/LEPTO

FECAL (STOOL SAMPLE)

HEARTWORM TEST/PREVENTION?

YOUR CAT’S VACCINATION HISTORY(Last date given):

RABIES

DIST-RHINO (FVRCP)

Feleuk/FIV Test

Feleuk Vaccination

FECAL (STOOL SAMPLE)

Any previous concerns such as serious illnesses, surgeries, allergies to vaccinations, special diets or medications?_____________________________

As the primary owner of the above animal(s), I am authorized to make decisions pertaining to care and treatment for the aforementioned pet(s). I am at

least 18 years of age. I understand that I am responsible for keeping the authorized names list current. I also understand that by signing this agreement

I will be held financially responsible to Asheville Highway Animal Hospital for rendering of all services and/or goods.

_________________________________________________________________________________________ (signature of primary owner)